To submit record requests from The Neuroscience Team, please print and fill out this form, then fax to 877-977-0511.
Alternatively, provide your information below so we can contact you.
Please specify which records you would like to have released. It is not generally in the patient’s interest to release all progress notes of sessions held, since this cancels all patient confidentiality; for this we recommend request of a summary, instead. Specify which reports should be released (Psyc Eval, Brain Map, etc).